HomeMy WebLinkAboutG-12-434 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK/
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y �; �. ,i< t. - ,,, MA DATE PERMIT f-
JOBSITE ADDRESS r �r— _ Y
i _ , .�,4 ./ �' �, OWNER'S NAME �...—�j Qat _.-..-�
GOWNER ADDRESS �� dor � _ �TELIj.�pB,cRaSFAXC _
TYPEPRIOR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONALQ RESIDENTIAL .
CLEARLY NEW:[ja RENOVATION:0 REPLACEMENT:KV.-- PLANS SUBMITTED: YES NOS!!
APPLIANCES 7 FLOORS-. BSM 1 2 3 . 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER ad_ _ t
CONVERSION BURNER wem ih „9. ! �� I " r a A irs 1g,15 ' ��
COOK STOVE I yiDIRECT VENT HEATER l iI ,� I 'I - #icii
1 t `" 01�#
DRYER - .v�_ Lr..r = 's..:-_„ a ;:e'.
FIREPLACE ... BU 01N; EPT amillilt
FRYOLATOR ' l t
FURNACE
GENERATOR
GRILLE / I 14e.,-14. sr� r., SA� ..., ..—.a;:. y ..:
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INFRARED HEATER i s r 1I I i
LABORATORY COCKS ; I
MAKEUP AIR UNIT I + d jx Irr II.: l as
OVEN _ r. j I
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POOLHEATERi
ROOM/SPACE HEATER I I 1.
ROOF TOP UNIT fi ` I
TEST r -' s :a •,,;,} e.r ' _ I r• A ..x +, r. -
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UNIT HEATER t � _
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UNVENTED ROOM HEATER -
WATER EA, ..._ 7
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OTHER _ 0.0.011111.11111131111111111111111111
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [I'•NO U,i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 4r OTHER TYPE INDEMNITY [J BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 3 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbingwork and Installations performed under the permit issued for this application will be in corn 'ance with all ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws..- C
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PLUMBER-GASFITTER NAME[84 .p . + fi x, 0. LICENSE#Jena! SIGN �
MP sr. MGFL„ JP EJ JGF 0 LPGI❑ CORPORATION,lEJ.,#/ PARTNERSHIP __]LLCr #n .
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COMPANY NAME:r3 S E 1... jADDRESSL/fl ,�`/ rn _��.. 711
CITY ':._. Oe2 i t,ri" i ! STATE,WJA ZIP[ 77' ITEL{tOR-Jf-a cycy:._.._.....„..J
FAX _ : CELLI• _ „= EMAIL� _,_. � •�a�;5-ip�[Gc2,6 Ly�r ...�... ;
SOr a 7V/-Vs-/ ,l"-OR-SW 7a8y
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
•
FEE: $ PERMIT#
PLAN REVIEW NOTES
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